The Efficacy of Prophylactic Antibiotics Administration prior to Insertion of Tunneled Catheter in Hemodialysis Patients

Abstract

Aim and background: Central venous catheter (CVC)-related blood stream infection is a major cause of morbidity and mortality in patients with end-stage renal diseases. However, CVCs are quite frequently required for vascular access in hemodialysis (HD) patients. Tunneled catheters (TCs) are widely used when a catheter is needed for a long period. However, long-term catheter survival is limited by TC-related infections. The purpose of this prospective study was to assess clinical outcomes of prophylactic antibiotics administration prior to insertion of TCs in HD patients. Material and methods: Sixty uremic patients who required TC insertion due to vascular access failure were included in our study between April 2009 and April 2010. Patients were randomized into two groups: group I and group II. Group I received 1 g of cefazolin sodium intravenously 1 h prior to catheter insertion. Group II received equal amount of saline intravenously 1 h prior to catheter insertion. The primary end points of the study were catheter loss, hospitalization, or mortality due to catheter-related infections (CRIs). The secondary end points included exit-site infection (not requiring hospitalization), tunnel infections (not requiring catheter removal), and bacteremia. Results: During the follow-up period, one patient in group I and three patients in group II reached primary end point (p < 0.05). Catheter loss due to infection was higher in group II than in group I as 6 versus 3, respectively (p < 0.05). Catheter exit-site infections, which does not require hospitalization, have been considered as secondary end points and have been detected in four patients for 7 times in group I and in six patients for 10 times in group II (p < 0.05). Tunnel infection, which does not require removal of the catheter, has been detected in two patients for 3 times in group I and in five patients for 6 times in group II (p < 0.05). Conclusion: The prophylactic antibiotic use prior to TC insertion significantly reduced CRIs, bacteremia, and catheter loss.

• catheter-related infections
• hemodialysis patients
• tunneled catheter
• cefazolin prophylaxis
• catheter loss

INTRODUCTION

Central venous catheters (CVCs) and arteriovenous fistulas (AVFs) are widely used in hemodialysis (HD) practice. The HD catheters have been used for long-term vascular access in a small proportion of patients, alternative to arteriovenous access. The main advantages of the catheters are easier admission, immediate access for HD, availability of various sites in the body, and not causing hemodynamical disturbances such as AVFs. Luminal occlusions, infections, patient discomfort, and shorter availability than AVFs are the some of the disadvantages.

Recently, it was reported that 15–50% of patients in Europe and 60% of patients in the United States start HD treatment with a catheter as primary access. Widespread use of catheters implies an enhanced risk for catheter-related complications, particularly catheter-related infections (CRIs).¹ In order to decrease the incidence of infectious complications, tunneled catheters (TCs) are recommended for long-term application.²

CRIs (incidence has been reported as 0.6–6.5/1000 catheter days) are the most common late complications.^3–6 The material of the inserted catheter, insertion technique, and hygiene precautions are the most important factors to avoid catheter-related complications. To date, no consensus has emerged concerning the use of prophylactic antibiotics for TC insertion.² In this study, we aimed to evaluate the effectiveness of prophylactic cefazolin administration prior to TC insertion.

MATERIALS AND METHODS

Our study included 60 uremic patients who required TC insertion due to vascular access failure between April 2009 and April 2010. Patients are randomized into two groups: group I and group II. Group I received 1 g of cefazolin sodium intravenously 1 h prior to catheter insertion. Group II received equal amount of saline 1 h prior to catheter insertion. TCs were inserted by experienced nephrologists under direct image guidance with maximum sterility and barrier cautions. The Amecath Permthane catheters (14.5 F, dual-lumen cuffed catheters used only for HD) were used in all patients. Patients with prior mechanical complications during catheter insertion, prior TC presence, immunosuppressive drug use, or other immunosuppressive disease, have been excluded. During the follow-up of the patients, catheters have been taken care of by the dialysis nurses using sterile equipments and 10% povidone iodine.

The primary end points of the study were catheter loss, hospitalization, or mortality due to CRIs, and the secondary end points were exit-site infection not requiring hospitalization, tunnel infections not requiring catheter removal, and bacteremia.

Study Ethic

The study was approved by the Ethics Committee and was conducted in accordance with the ethical principles described by the Declaration of Helsinki. Written informed consent was obtained from all participants.

Statistical Analyses

SPSS 16.0 statistical program was used for statistical analyses. All values are presented as mean ± standard deviation (SD). Values between different groups were compared using the independent samples t-test. The Fisher’s exact test was used to assess differences between the categorical variables. p-Values 0.05 were considered statistically significant.

RESULTS

There was no statistically significant difference between the groups in terms of demographic data (Table 1).

Table 1.  Demographic data of the patients.

	Prophylaxis group	Control group
Age (year)	51.23 ± 6.8	50.32 ± 4.6
Male/female (n)	14/16	15/15
Hemodialysis vintage (months)	43 ± 3.6	39 ± 2.4
Etiology of renal disease (n)
Hypertension	9	10
Diabetes mellitus	10	9
Glomerulonephritis	5	4
Amyloidosis	2	2
Unknown	4	5
Hemoglobin (g/dL)	10.8 ± 0.8	10.9 ± 0.5
CRP (mg/L)	0.9 ± 0.3	0.8 ± 0.4
Albumin (g/dL)	3.7 ± 0.4	3.8 ± 0.5

Table 2.  The evaluation of the patients in terms of tunneled catheter-related infection.

	Prophylaxis group	Control group	p-Value
Catheter loss due to infection (n)	3	6
Tunnel infection (n)	2	5
Exit-site infection (n)	4	6
Bacteremia (n)	6	10

Note: *p < 0.05.

Two patients from group I and three patients from group II have been deceased due to cardiovascular and cerebrovascular diseases. During the follow-up period, one patient in group I and three patients in group II reached primary end point (p < 0.05). Catheter loss due to infection was higher in group II than in group I (6 vs. 3, respectively, p < 0.05). The median duration of catheterization before removal was 8 months^6–10 in group I and 5.5 months^3–10 in group II, respectively.

Catheter exit-site infections not requiring hospitalization have been detected in four patients for 7 times in group I and in six patients for 10 times in group II (p < 0.05). Tunnel infections not requiring removal of the catheter have been detected in two patients for 3 times in group I and in five patients for 6 times in group II (p < 0.05). Bacteremia has been encountered in 6 patients for 8 times in group I and in 10 patients for 13 times in group II (p < 0.05).

The evaluation of the patients in terms of tunneled CRIs is shown in Table 2.

DISCUSSION

In this study, it was demonstrated that prophylactic antibiotic use prior to TC insertion significantly reduces CRIs, bacteremia, and mortality. In addition, it also showed that the administration of prophylactic antibiotics on the day of catheter insertion prolonged catheter survival.

Sepsis is the second leading cause of death in patients with end-stage renal disease on HD.⁷ The HEMO study demonstrated that more than 42% of the 1846 patients were hospitalized at least once for an infection. Analysis revealed that approximately 58% of patients who were hospitalized for an infection for the first time had a severe outcome, including death, intensive care unit stay, or prolonged hospitalization.⁸ CVCs in HD patients are used for vascular access when the surgical AVFs are not available. Using a CVC is considered as a major risk for bacteremia in HD patients. It was demonstrated that relative risk for catheter-related bacteremia has increased 7 times when compared with AVFs.^9,10 Avoiding unnecessary catheterizations and removing the catheter as soon as possible are the main factors reducing the risk of CRIs. As the duration of the catheter use gets longer, it is expected to be associated with higher incidence of CRIs. When it is estimated that the CVCs will be used for longer than 3 weeks, it is recommended to insert cuffed catheters.¹¹ The cuff at the end site of the catheter reduces bacterial colonization and bacterial migration from the exit site. TCs are more comfortable and less likely to become infected than the non-TCs. However, current TCs, which were introduced for longer periods of use, did not decrease any CRI or thrombosis to date.¹²

During CVC insertion, some parameters should be taken into account in order to avoid CRIs, including proper use of the aseptic technique, hand hygiene, and using sterile barriers. Antibiotic-containing creams and prophylactic antibiotic locks are recommended for high-risk patients.¹¹ There have been no recommendations about the use of prophylactic antibiotic administration to HD patients.

A meta-analysis containing four clinical trials revealed that prophylactic glycopeptide medication has controversial results.¹³ Van de Wetering et al. found that prophylactic antibiotic prior to the insertion of TC decreases the number of Gram-positive CRI, but the effect is not significant. Another study demonstrated the prophylactic administration of vancomycin prior to the insertion of TC did not reduce catheter-related sepsis.¹⁴ In addition, Sandoe et al. showed that prophylactic antibiotic use has no benefit in order to avoid colonization of CVCs.¹⁵ In another study, which included 371 infants who have CVCs for parenteral nutrition, the prophylactic vancomycin versus placebo has been compared for CRIs. There were no difference between the groups in terms of mortality and duration of hospitalization.¹⁶ However, none of these trials have included HD patients and there have been no discrimination according to the catheter type such as TC. In this study, prophylactic antibiotic was administrated to the HD patients prior to the insertion of TC. Contrary to the results obtained by these studies, the use of prophylactic antibiotic treatment in our study showed a remarkable decrease in CRIs.

Gram-positive organisms are responsible for most dialysis CRIs. Coagulase-negative Staphylococcus and Staphylococcus aureus together account for 40–80% of cases with CRIs.¹⁷ The cefazolin monotherapy as initial antibiotic treatment in HD patients with CRIs appears as more effective than vancomycin for treatment of methicillin-sensitive Staphylococcal infections.¹⁸ Furthermore, the widespread use of vancomycin has been associated with an increasing incidence of infections due to vancomycin-resistant Enterococci.¹⁹ In our study, cefazolin prophylaxis prior to catheter insertion was performed as the first choice because of the aforementioned factors.

Moreover, the prophylactic use of antibiotic locks in HD patients with TC reduces the rate of CRIs, but there are no data regarding the long-term consequences of this practice.²⁰ However, antibiotic lock solutions emerged antibiotic resistant.²⁰ In addition, antibiotic lock treatments (vancomycin, gentamicin, or minocycline) are not cost-effective. Our study shows that the use of cefazolin prophylaxis prior to insertion of TC may be an alternative to antibiotic lock solution.

In conclusion, using cefazolin prior to the insertion of TC is an effective and safety treatment to prevent CRIs. In addition, this treatment is more cost-effective rather than antibiotic lock treatments. However, more prospective studies with large number of patients are needed to determine the prophylactic cefazolin administration in patients with HD.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the manuscript.